Finally, examine for eye signs and hands to complete the thyroid examination

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THYROID EXAMINATION – PRESENTATION

This patient is having a lump in the anteroinferior aspect of the neck which moves up with deglutition. There are no visible surgical scars in the neck or dilated neck veins and Pemberton’s sign is negative.

The lump is firm in consistency and its surface is nodular with a prominent nodule in the right upper lobe. There is no cervical lymphadenopathy. Its lower border can be felt, trachea is deviated to the left side and the right carotid pulse is deviated posterolaterally. There is no bruit. She is clinically euthyroid and there are no thyroid eye signs.

So, my probable diagnosis is a clinically euthyroid longstanding multinodular goiter (MNG) without retrosternal extension. I would like to investigate her with a thyroid profile, USS neck and FNAC of the prominent nodule to decide on further management

FREQUENTLY ASKED QUESTIONS

1. What are the causes of diffuse thyroid enlargement?

1. Simple colloid goiter. 2. Thyroiditis. 3. Grave’s disease.

2. What are the differential diagnosis for a solitary nodule of the thyroid (SNT)?

Inguinal Hernia (OSCE Guide)

Inguinal Hernia (OSCE Guide)

Examination of an inguinal hernia is a vital part of surgical examination methods. It is one of the most basics skills that every medical student and doctor should be aware of.

More importantly, differentiating between a femoral and inguinal hernia plays a major role here.

Firstly, introduce yourself and get consent before you proceed to examine the patient.

INGUINAL HERNIA EXAMINATION

You will be asked to examine the groin area of a patient who is lying supine, but always remember to examine the patient in the erect position as well, at some point in your examination.

Get the Consent, cover the area and expose adequately.

Look carefully for surgical scars in the groin (Recurrent hernia?).

See the shape of the lump in the groin. A direct inguinal hernia is usually globular in shape and an indirect one may be sausage-shaped (inguinoscrotal swellings).

Ask the patient to cough,

To elicit expansile cough impulse.

Inorder to visualize a hernia that cannot be seen.

To see the full extent of an already visible hernia.

ONLY IF the hernia still cannot be seen, ask the patient where the lump is (It may be a scrotal swelling!!) and ask him to stand up at this point & look for a bulge appearing on the groin area on coughing (Very rare to give invisible ones in an exam setting).

Once the hernia is visible, demonstrate the palpable expansile cough impulse.

ONLY IF there is no past surgical scar indicating a previous repair, differentiate whether it is direct or indirect hernia.

Ask the patient himself to reduce the hernia fully for you.

If the patient is unable to do so, ask the examiner whether you may try to reduce it (DO NOT try to reduce without the consent of the examiner)

Ask to cough while you are applying firm pressure on deep inguinal ring with your index finger.

If the lump can be controlled by digital pressure over the deep ring, it is an “Indirect inguinal hernia”, if not it is a “Direct inguinal hernia”.

Examine the external genitalia to exclude phimosis and coexisting scrotal lump which is very common.

If the patient was supine throughout your examination, ask him to stand up before you finish and look for,

A coexisting small hernia on the other groin.

A coexisting varicocele.

PRESENTATION

This patient has got a globular shaped lump in the right groin region. It has visible and expansile cough impulse. The hernia can be completely reduced and cannot be controlled by applying firm pressure over the deep inguinal ring. He has got no phimosis and there are no coexisting scrotal lumps. The contralateral groin is normal. So my probable diagnosis is uncomplicated right-sided direct inguinal hernia and I would like to offer him inguinal hernia repair under spinal anesthesia.

2. If you see a scar of a previous repair, do you still want to locate the deep inguinal ring?

No. Once a hernia is repaired, its anatomy is disturbed. So a recurrence of a hernia arises from the weakest part of it. Hence it is neither direct nor indirect.

3. If you cannot control the hernia by applying firm pressure over the deep inguinal ring, can it still be an indirect hernia? Why?

Yes, it can be. 1. Not enough pressure applied. 2. Finger is not on the deep inguinal ring. Anyway, this method is just for crude assessment. The direct or indirect nature of a hernia is best identified during the surgery.

4. From where does an indirect inguinal hernia appear?

It comes from deep inguinal ring, passes obliquely through the inguinal canal and may continue through the superficial inguinal ring to the scrotum. It arises lateral to the inferior epigastric artery. Commonly due to persistent processes vaginalis.

5. From where does a direct inguinal hernia appear?

It occurs as a result of weakened posterior wall of the inguinal canal and arise medial to the inferior epigastric artery. So a direct inguinal hernia is not within the spermatic code. It may descend to the scrotum though.

6. What is the importance of differentiating direct and indirect inguinal hernia?

No importance! Management is the same for both.

7. What is the landmark to differentiate direct from indirect inguinal hernia during the surgery?

Ulcer Examination (OSCE Guide)

Ulcer Examination (OSCE Guide)

Ulcer Examination is a basic short case OSCE skill for all doctors and medical students.

Firstly, introduce yourself and get consent before you proceed to examine the patient. Examination of an ulcer is more or less similar to an examination of a lump. But some additional features have to be kept in mind.

PRESENTATION

Venous UlcerThere is an ulcer over the right ankle just above the medial malleolus (Gaiter’s area). It is oval in shape, approximately 2cm x 3cm in size. Its margin is irregular, edge is sloping and the floor contains healthy granulation tissue. There is a serous discharge from the ulcer. The ulcer is superficial and the base contains subcutaneous tissue. The surrounding skin is warmer, pigmented and thickened. There are associated varicose veins. Peripheral pulses and sensation are normal and there is no inguinal lymphadenopathy.

Neuropathic UlcerThere is an ulcer over the sole of the right foot which is oval in shape, approximately 3cm x 4cm in size. Its margin is regular, edge is punched-out and floor contains healthy granulation tissue. There is no discharge from the ulcer. Ulcer is painless, the base contains flexor tendons of toes, surrounding skin and peripheral pulses are normal. Peripheral sensation to pain is absent up to ankles and joint position sensation is impaired.

Ischemic Ulcer There is an ulcer over the tip of the 2nd toe of the right foot which is round in shape, approximately 1cm x 1cm in size. Its margin is irregular, edge is punched out and floor contains slough. There is a purulent discharge from the ulcer. The base contains bone of the distal phalanx. The surrounding skin is colder and blackish in colour. Dorsalis pedis and posterior tibial pulses are absent and the femoral pulse is weak on the right side. The peripheral sensations are normal and there is no inguinal lymphadenopathy.

Malignant UlcerThere is an ulcer over the dorsum of the right foot which is irregular in shape, with a maximum diameter of 6cm. There is a purulent discharge from the ulcer. Its margin is irregular, the edge is raised & everted. Floor is reddish-brown and contains slough. There is hard inguinal lymphadenopathy on the right side. Peripheral pulses and sensation are normal.

FREQUENTLY ASKED QUESTIONS

1. What is an ulcer?

It is a break in the continuity of an epithelial surface.

2. Explain the terms margin, floor, edge and base of an ulcer.

1. Margin – The line of demarcation between normal and affected tissue. 2. Floor – Exposed bottom of the ulcer. 3. Edge – It connects the margin to the floor. 4. Base – The area in which the ulcer rests.

Examination of a Lump (OSCE Guide)

Examination of a Lump (OSCE Guide)

Examination of a lump is a component in almost every surgical clinical examination. Sometimes you may be asked to spot diagnose a lump with just inspection. Given below is a rough guide to the examination of a lump.

PRESENTATION

There is a hemispherical shaped lump, over the left lateral aspect of the neck, measuring 5cm x 5cm in size. The overlying skin looks normal. Its surface is smooth and the edge is well defined. It is mobile and not attached to the skin or the underlying structures. It is soft in consistency, fluctuant and transilluminant. It is not reducible or pulsatile and there is no associated lymphadenopathy.

Tip: If you are confident enough, make sure that you give a rational presentation, excluding the possibilities one by one for more marks.

FREQUENTLY ASKED QUESTIONS

1. How do you elicit the skin attachment of a lump?

Using the thumb of the examining hand, the skin over the lump is stretched in two directions perpendicular to each other. If the skin is freely movable over the lump, the lump is not attached to the skin.

2. Why “pinching” the skin over the lump is not the ideal way?

This method is not accurate as the lump may be attached to the skin at a point other than the site of pinching.

3. How do you elicit fluctuations?

First, the lump should be fixed between the two feeling fingers (the index finger and the thumb) of one hand and press on the lump using the index finger of the other hand. If you can see the feeling fingers moving apart with each press, it is fluctuant. The same technique of examination should be carried out twice in two directions perpendicular to each other, “Cross Fluctuations”.

4. If it is fluctuant, what does that mean?

That means the lump is cystic; in other words, it contains fluid. But lipomas (fat cells) can show pseudofluctuations.

5. If it is trasilluminant, what does that mean?

That means the fluid inside is clear and does not absorb light. Some lumps are brilliantly transilluminant.

Lipoma Examination (OSCE Guide)

Lipoma Examination (OSCE Guide)

Lipoma Examination is a basic short case OSCE skill the undergraduates must-have. Firstly, introduce yourself and get consent before you touch the patient.

LIPOMA EXAMINATION

1. Site – Commonly over the front and back of the chest. 2. Size -Medium to large. 3. Shape – Hemispherical. 4. Skin – Scar? (Recurrence?) 5. Surface – Lobulated. 6. Edge – Well defined. 7. Tissue plane – Freely mobile (Slipping sign). Not attached to skin or underlying muscle. Try to elicit the tissue plane of the lipoma by contracting the underlying muscle. When the muscle is contracted, ✓ If the lump becomes prominent – a subcutaneous lipoma. ✓ If the lump becomes less prominent – an intramural lipoma. 8. Consistency – Soft to firm depending on the nature of fat within it. 9. Fluctuance – Fluctuant (Pseudofluctuant). 10. Transillumination – May be transilluminant

PRESENTATION

There is a hemispherical shaped lump, measuring 5 cm in diameter, over the right scapula. It is not tender, the surface is lobulated and the edge is well defined. The lump is freely mobile. It is not attached to the skin or the underlying muscle. It is soft in consistency, fluctuant and transilluminant. So, my probable diagnosis is a lipoma and I would like to offer him surgical excision under LA if it is cosmetically unacceptable.

FREQUENTLY ASKED QUESTIONS

1. What is a lipoma?

It is a benign tumour that consists of mature fat cells.

2. What is Dercum’s disease?

It is characterized by multiple painful lipomas.

3. Can they undergo malignant transformation?

No. But liposarcoma can occur de novo.

4. What is the treatment for lipoma?

Usually by reassurance. But surgery is offered if the patient complains of pain or if it is cosmetically unacceptable. It is removed by either simple surgical excision under LA. Alternatively, suction lipolysis can be used.